A Qualitative Study of Smoking Behaviors among Newly Released Justice-Involved Men and Women in New York City

Abstract

Long-term effects of cigarette smoking result in an estimated 443,000 deaths each year, including approximately 49,400 deaths due to exposure to secondhand smoke. Tobacco is a major risk factor for a variety of chronic health problems, including certain cancers and heart disease. In this article, authors present qualitative findings derived from individual interviews with men and women who were incarcerated in New York state and New York City. Participants were 60 racially and ethnically diverse men and women ages 21 through 60 (M = 46.42, SD = 6.88). Of the participants interviewed, 91.7 percent released from a smoke-free correctional facility resumed cigarette smoking and 8.3 percent remained abstinent. Daily consumption ranged from smoking four cigarettes to 60 cigarettes. The four themes that emerged from the study were (1) lifetime exposure to cigarette smoking influences smoking behavior; (2) cigarettes help relieve stress and are pleasurable; (3) there is a relationship between access, availability, and relapse; and (4) smoking cessation strategies are available. Negative influences from participants’ families and peers, stressful housing situations, and mandated programs emerged from this study as key challenges to abstaining from smoking cigarettes. Involving family members and partners in smoking cessation interventions could influence newly released justice-involved men and women not to resume cigarette smoking and possibly maintain long-term abstinence.

Cigarette smoke results in an estimated 443,000 deaths each year, including approximately 49,400 deaths from exposure to secondhand smoke (U.S. Department of Health and Human Services [HHS], n.d.). Tobacco use is a major risk factor for a variety of chronic health problems, including certain cancers and heart disease (HHS, n.d.). An estimated 19.3 percent of the U.S. adult population (45.3 million individuals) were smokers in 2011; however, the smoking prevalence in previously incarcerated populations has consistently been shown to be substantially greater than in the general population, with around 60 percent to 80 percent opting to smoke on release to the community (Cropsey, Jones-Waley, Jackson, & Hale, 2010; King, Dube, Kauffman, Shaw, & Pechacek, 2011).

The Federal Bureau of Prisons made all facilities under its control 100 percent smoke free in July 2004. In state prisons and jails, correctional officials have adopted varying degrees of smoke-free resolutions that promote either smoke-free policies or prohibit smoking in their facilities altogether (American Nonsmokers’ Rights Foundation, 2015). Despite the pervasiveness of U.S. correctional smoke-free policies, there are still many questions regarding their effectiveness. For one, enforcement of and compliance with these policies are highly variable and, as a consequence, banning cigarettes does not ensure abstinence from tobacco use on release from a correctional facility (Foley, Proescholdbell, Herndon Malek, & Johnson, 2010). For instance, Cropsey and Kristeller (2005) found that 76 percent of the prisoners who smoked prior to a prison smoking ban still reported some level of smoking one month after being released from the facility. In addition, even if smokers are able to quit while incarcerated, mounting evidence suggests that forced abstinence in prison does not result in sustained nonsmoking behavior on release (Cropsey & Kristeller, 2005; T. Lincoln et al., 2009). T. Lincoln et al. (2009) found that 97 percent of prisoners relapsed within six months of release back to their communities.

SMOKING BEHAVIORS AND INTENTIONS TO QUIT IN JUSTICE-INVOLVED POPULATIONS

A better understanding of the smoking behaviors and intentions to quit among individuals involved in the criminal justice system may be critical to reduce tobacco use in this population. Cropsey and Kristeller (2005) found that individuals who continued to smoke after release from a tobacco-free facility were more nicotine-dependent and reported more withdrawal symptoms, even after accounting for baseline nicotine-dependence and baseline withdrawal scores (Cropsey & Kristeller, 2005). In another study, Voglewede and Noel (2004) found that smokers with a strong desire (craving) for tobacco were more likely to intend to smoke on release from jail. Interestingly, they found no relationship between intent to smoke and length of incarceration or level of nicotine dependence (Voglewede & Noel, 2004).

We know very little about how individuals who are supervised in the community (parole or probation) rebuild their lives with respect to their tobacco habits after being released from smoke-free correctional facilities. To learn more about this issue, we asked the participants (a racially and ethnically diverse group of men and women released from New York correctional facilities) to describe their smoking behaviors before, during, and after incarceration and their intentions to quit tobacco use during these same time periods.

In this qualitative study, we explored the following three research questions: (1) What are the smoking behaviors and intentions to quit tobacco in justice-involved populations? (2) What are the social characteristics that support or encourage tobacco resumption? (3) What smoking cessation programs, if any, are provided to, or sought out by, the study participants upon their release from tobacco-free correctional facilities?

METHOD

Qualitative data presented here were gathered from men and women who were formerly incarcerated in a New York state prison or the Rikers Island jail in New York City (NYC), and who returned to reside in the Bronx, New York. Among the 60 participants were 13 black men and 19 black women, 17 Latino men and eight Latina women, and three white women (but no white men), and they ranged in age from 21 through 60 years (M = 46.42, SD = 6.88). Of the participants interviewed, 58 percent were released within one year; 66 percent served in both prison and jail; 23 percent served jail time only; 10 percent served in prison only; and one participant was involved in an alternative-to-incarceration program. The age of first incarceration ranged from 18 to 52 years (M = 29.87, SD = 14.75).

In terms of the participants’ levels of education, 45 percent of participants (11 women and 16 men) did not complete high school or obtain a GED diploma; 35 percent of participants (11 women and 10 men) graduated from high school or obtained a GED; and the remaining 20 percent (eight women and four men) attained some college education in the form of some college credits, a bachelor’s degree, or a master’s degree. The age when the participants left school ranged from four years old to 24 years old (M = 15.95, SD = 3.34). The participant who indicated that he or she left school at age four did not have any formal schooling. In terms of participants’ marital status, nearly half (48.3 percent; 15 women and 14 men) were single or never married; 25 percent (four women and 11 men) were married; and the remaining were divorced (five women and three men), separated (five women), or widowed (one woman and two men). The number of children among the participants ranged from zero to 10 children (M = 2.40, SD = 1.80). The institutional review boards at Albert Einstein College of Medicine and Columbia University approved the research procedures, and the first author obtained a National Institutes of Health Certificate of Confidentiality.

Setting

In New York, approximately 74 percent of individuals in the custody of the Department of Corrections and Community Supervision are black or Latino (State of New York Department of Corrections and Community Supervision, 2012). Of the 13 NYC community districts that have the highest rates of incarceration (greater than 10 inmates per 1,000 residents), six are located in the Bronx. In the district with the highest incarceration rate of 12 per 1,000 residents (containing Morris Heights, University Heights, Fordham, and Mt. Hope), 41 percent of the residents of these district are impoverished, and 58 percent receive public assistance (Mellow et al., 2008). Overall, 31 percent of Bronx residents live below the federal poverty level.

The Bronx has one of the highest rates of current smokers in NYC at 18.0 percent, compared with 15.2 percent in Manhattan (New York City Department of Health and Mental Hygiene, n.d.). Because of the borough’s higher-than-average smoking rate and its significant population of formerly incarcerated individuals living in the county, the research team chose the Bronx as a model setting for this study. The borough offers a large population of study participants to draw from; lessons obtained from this study’s focus areas can thus be more broadly applied to other communities of color.

Measures

The semistructured interview format was flexible to allow participants to respond to questions naturally, but structured enough to keep the discussion on relevant topics. The interview questions were developed by the first author. The following are examples of the interview questions:

• How many packs of cigarettes do you smoke daily?

• What type of cigarettes do you typically smoke?

• Could you please describe a situation when you need a cigarette?

• How long were you smoking before you were incarcerated?

• How does smoking cigarettes make you feel?

• Why do you smoke now?

• How do you obtain money to buy cigarettes?

• Have you tried to quit? (Probe question: If yes, what have you tried—nicotine patch, therapy, self-help, and medication?)

• When was the last time you tried to quit?

• How has your smoking behavior changed since coming home from prison or jail?

• How much do you spend per week on cigarettes?

• Do you have family members who smoke cigarettes? (Probe for any members dealing with cancer-related to cigarette smoking or tobacco use.)

Procedures

Participants were recruited through flyers advertising the study placed in criminal court buildings, drug and rehabilitation centers, and social services agencies working with individuals involved in the criminal justice system. Potential participants were asked to contact the research office to determine eligibility. The first author and her research team (master’s-level public health and social work students who were trained in qualitative research methods) recruited study participants and conducted the individual interviews during a six-month period in 2011.

To participate in this study, individuals had to meet the following eligibility criteria: (a) self-identify as a male or female; (b) age 18 years or older; (c) reside in Bronx, New York; (d) under community supervision (parole or probation); (e) report no previous diagnosis of cancer; (f) report substance use history; (g) provide informed consent; and (h) agree to the interview being digitally recorded. We also invited participants to refer friends and peers who met eligibility criteria. The interviews ranged in length from 90 to 120 minutes. All interviews were conducted in a private meeting space, and all participants were compensated in cash for their participation.

Data Analysis

The digital recordings of the interview data were transcribed verbatim by a professional transcriptionist; NVivo 10, a qualitative software package, was used to manage and code the data. The first and second authors analyzed the data using content analysis to develop the smoking behavior codebook. Categories were developed and refined using passages retrieved from the transcripts; the data that were in close associations were grouped together and assigned a tentative code (Hsieh & Shannon, 2005).

We created a table in Microsoft Excel that listed the first-level codes, second-level categories, and potential subheadings as an initial template of the codebook. This stage involved identifying relationships among the codes and developing connections or relationships within the codes that we previously identified. We also created definitions and used the passages to illustrate the inclusion and exclusion criteria for each code. We reread the transcripts related to smoking and the codes selected, followed by the construction of the codebook; we used statements from the participants to support and define the code (Hsieh & Shannon, 2005). The codebook allowed the authors to code passages in which participants described their smoking behaviors and intentions to quit. When discrepancies occurred during coding, we met to discuss the differences until consensus was reached.

We assessed the credibility of our analyses in several ways. First, we reviewed the findings with several participants to ensure that the analyses and interpretations of the data reflected the interviewees’ own experiences and perceptions, thus minimizing researchers’ biases (Kirk & Miller, 1986; Y. S. Lincoln & Guba, 1985). Second, we were intensely engaged in the research, conducting multiple reads of the transcripts, met for several months to address discrepancies in the coding process, and ensured that our analyses and interpretations were rooted in the data. Third, we used bracketing to ensure that our assumptions and beliefs did not influence our analysis (Creswell & Miller, 2000). This included writing memos throughout data analyses and reflecting on how we engaged the data.

RESULTS

Of the participants released from a tobacco-free correctional facility, 91.7 percent (n = 55) resumed smoking cigarettes after release; only 8.3 percent (n = 5) remained abstinent.

Cigarette Smoking Habits

There were many commonalities in the smoking behaviors of the participants. The majority of the interviewees smoked Newport menthol cigarettes (including “loosies” or single Newport Menthol cigarettes and bootleg Newports), followed by rollies and natural cigarettes. The daily smoking behaviors ranged from four cigarettes (light smoker) to 60 cigarettes (heavy smoker), the equivalent of three packs per day (M = 17.2, SD = 12.81).

The majority of the participants spent $11.50 to $16.00 per day on a pack of cigarettes; others spent $0.50 or $0.75 for a single cigarette, or $7.00 on bootleg cigarettes. Bootleg cigarettes are cheaper because they are sold with a counterfeit tax stamp or with no tax stamps at all. On average, participants spent $40 to $50 per week on cigarettes. Some participants borrowed cigarettes from friends.

A little over half (51.6 percent) of the participants claimed they had no knowledge about the health effects of smoking. Despite this, 12 participants reported tobacco-related illnesses, including heart disease, asthma, and advanced emphysema. In addition, six participants reported that lung and bone cancer (n = 5) and myocardial infarction (n = 1) were the causes of death of a family member.

The four most salient themes that emerged from the data were (1) lifetime exposure to cigarette smoking influences smoking behavior; (2) cigarettes help relieve stress and are pleasurable; (3) there is a relationship between access, availability, and relapse; and (4) smoking cessation strategies are available.

Theme 1: Lifetime Exposure to Cigarette Smoking Influences Smoking Behavior

Participants were exposed to secondhand smoke primarily through caregivers. Many of the participants began smoking cigarettes at a very early age (from five through 15 years old, M = 12.5). When asked how he acquired his first cigarettes, a Latino male participant, age 43, incarcerated for over 15 years, and released less than six months prior to the interview, said, “I stole my mother’s cigarette. And I just went and I smoked it, and from then on after I puffed a couple of times, there it goes.” A Latina female participant, age 43 years, incarcerated for less than six months in a jail facility, and released less than six months prior to the interview, said, “My mother used to stay with us ... she used to put cigarettes in our mouths because we did not know how to smoke. And I learned how to steal cigarette[s] from my mother.” Unfortunately, the participants did not have family members teaching them about the importance of not smoking; instead of being talked to about the dangers of smoking, it was more common for participants to have family members who smoked. The vast majority of the study participants (70 percent) stated that having smokers as family members influenced their smoking behaviors during the reentry process. Several participants discussed having family members who are currently smokers. For example, “My mother, she smokes a lot. And, I hear her coughing at night. I say, ‘Mommy, you smoke a lot. We gotta stop smoking.’ She gets angry. I say we need to,” noted a black male participant, age 48 years and involved in an alternative-to-incarceration program.

Some participants expressed concern that many people in their family smoked. For example, a black female participant, age 45 years, who experienced both jail and prison time and was released less than three years from the time of the interview, said, “My uncle smokes. My sister smokes, my nephew smokes, and my son smokes. But they don’t smoke like chain smokers. I don’t know how they smoke. I know that they smoke; they indulge in cigarettes every now and then.” Another participant said:

My brother smokes. Well, all my brothers smoke. ... And, one of them has a pacemaker right now. Well, he got to really stop smoking. I think if I was at that level, I’d really stop smoking ... but you know, I been smoking since I was like 14. (black male participant, age 46, experienced jail and prison, and was released less than six months prior to the interview)

Family members play a very important role in justice-involved men and women’s ability to remain smoke-free after release from a correctional facility.

Theme 2: Cigarettes Help Relieve Stress and Are Pleasurable

Men and women who are newly released from a correctional facility face multiple challenges related to reintegration to society. Some face legal barriers to receiving public benefits; others struggle with mental illness, physical health conditions, substance use problems, or disability; and many are unemployed and often become homeless if there is limited transitional housing or family supports (La Vigne & Kachnowski, 2003). Community reentry is a stressful time for many men and women involved in the criminal justice system. Because of the extreme challenges to meet basic needs (such as stable housing, employment, and food), participants may engage in risky behaviors or old vices to cope with the stressful circumstances (Luther, Reichert, Holloway, Roth, & Aalsma, 2011). Although the participants did not engage in substance use, primarily because the majority of them were under community supervision, most (n = 55) reengaged in cigarette smoking on release and while in reentry.

In this study, a little over half of the sample (n = 35) denoted psychological pleasure in smoking cigarettes. The most common explanations for smoking cigarettes were “brings pleasure,” “relaxing,” “calms me down,” “reduces anxiety,” “puts me at ease,” and “makes me feel good.”

Study participants discussed the benefits of smoking cigarettes as they navigated the community reentry process. For over half of the participants, cigarettes helped to regulate and ease stressful experiences. A black female participant, age 47 years, who spent 16 months in jail and was released less than six months prior to the interview, was asked by the interviewer what she did when she “started feeling extra stress,” and rather than talk to a counselor, friend, family member, or probation officer about what she was feeling, she smoked more. Another participant, Latino, male, age 50, incarcerated for less than 30 days in jail and released less than six months prior to the interview, reported, “I feel more relaxed. You know, cigarettes relax me. I feel well ... I feel better.” Chain smoking was mentioned by the participants as a method that they used to destress.

Theme 3: Relationship between Access, Availability, and Relapse

Inmates released from prison and under community supervision who need a place to live may be sent to a structured transitional housing facility or a recovery housing facility, and parolees residing in these facilities have access to supportive services. However, some of these housing facilities are not smoke-free properties. In our study, a number of participants said that they reengaged in cigarette smoking immediately because cigarettes were readily available when they were released to transitional housing.

Interviewer: When did you pick up the first cigarette when you got home?

Interviewee: When I got to Facility A. I just went, got a loosie, and smoked it. I was dizzy as hell. I don’t know, I guess it was something to do.

Interviewer: Many people around you?

Interviewee: Yeah, everybody, almost all the girls there smoke. (Latina, female, 39 years old, eight months incarcerated in jail, and released less than six months prior to interview)

Living with other parolees in transitional housing facilities that are not smoke-free properties may be associated with reengaging in cigarette smoking. For instance, a black male participant, age 50 years, who spent less than six months in prison and was released less than six months prior to interview, stated, “Well, right now there are a lot of guys in the house that, you know, a lot of ’em are working, so it’s easy to get a cigarette sometimes. It’s not hard to get a cigarette.” Overall, men and women who are returning from correctional facilities are faced with overwhelming challenges to maintain a smoke-free lifestyle. They are paroled to programs and housing facilities where smoking is hard to resist.

Theme 4: Smoking Cessation Strategies Are Available

The final theme that emerged in the study was a sense of not resigning to a feeling of hopelessness because of one’s circumstances. Despite being exposed to a lifetime of cigarettes, returning to family members who are current smokers, and being mandated to programs and housing facilities that are not smoke-free, some participants felt that they had a choice whether to feel trapped or find approaches to remain smoke free. The last successful attempt for participants was when they were incarcerated and forced to quit. At least half of participants were working toward reducing the number of cigarettes smoked per day, mainly because of cost. Because cigarette smoking is an expensive habit, some participants described using the following strategies to save money and reduce the frequency of smoking cigarettes: “smoking less,” “using the nicotine patch,” “asking a physician for [smoking cessation] medication,” and “substituting candy for a cigarette.” During the interview, these participants felt confident that they would quit one day by using many of these strategies. Participants also cited removing tobacco products, pharmacotherapy, and quitting as a team as critical strategies to smoking cessation for justice-involved populations. Consistent with the latest trends on tobacco regulatory and control, CVS Caremark, a leading drugstore chain, is eliminating cigarettes and tobacco products from their store shelves. In addition, pharmacotherapy such as CHANTIX (varenicline) has been clinically proven to assist ’in smoking cessation (Hoogendoorn, Welsing, & Rutten-van Mölken, 2008). One participant (Latina, female, 53 years old, incarcerated for 1.5 years in jail, and released two years prior to this interview), had used Chantix:

I quit actually with Chantix, when I was in the jail. ’Cause we couldn’t smoke in there. I mean, people used to smoke and sneak, and get in trouble and lose their privileges. So when I saw I was heading down the road, I ... asked the doctor in the facility for Chantix. And it worked. ... I stopped smoking for eight months when I was incarcerated.

Another way to achieve smoking cessation was by encouraging former smokers and family members to “quit as a team.” When the interviewer asked, “Is your husband trying to quit when you quit?,” the black female participant, age 48 years, incarcerated in prison for two years, and released two years prior to interview, responded, “Yeah, we want to do it together. We won’t be in the house smoking together.”

Although only a few participants suggested that “quitting as a team” might be helpful to quit smoking, implementing a family or partner team approach in the community and offering a cessation program may improve motivation to decrease or quit smoking and keep former justice-involved participants from reengaging in the habit.

DISCUSSION

This qualitative study demonstrates that formerly incarcerated men and women released from correctional facilities lack the support from family, peers, and their environment to maintain abstinence from cigarette smoking following release from prison or jail. In fact, the smoking behaviors of family and friends and stressful housing situations and mandated programs emerged from this study as key challenges to maintaining abstinence. Regardless of lengthy abstinence from smoking cigarettes due to incarceration, study participants returned to smoking cigarettes postrelease. Our findings are consistent with those of Bock and colleagues (2013), who demonstrated that formerly incarcerated individuals have few social models for not smoking and generally lack strong social support from family and particularly from friends relevant to maintaining smoking abstinence after release.

Social factors, specifically homelessness, mandated court or community supervision programs, and a lifetime of exposure to family and friends who are cigarette smokers influence or shape their susceptibility to return to smoking cigarettes. The lack of available smoking cessation strategies to maintain abstinence on release to the community also contributes to relapse. In this study, our interviewees had the fewest resources to withstand societal changes (due to the stresses of living in transitional housing or securing a job, for example), which means that prolonged years in the confines of correctional institutions may have unintended consequences.

The majority of correctional facilities do not offer smoking cessation treatment (Kauffman, Ferketich, & Wewers, 2008). That being said, the relapse rate for smoking is highest the day after release from incarceration, which suggests that offering cessation services, both in correctional facilities and in the transition back to the community, may be critical to reducing tobacco use in this population (Clarke et al., 2013). Although smoking cessation programs are relatively rare in correctional facilities and even infrequent in the community for justice-involved populations, Cropsey et al. (2010) found that more than half of smokers reported that they would be interested in receiving smoking cessation assistance if free help was available. In particular, pharmacotherapy generated a lot of interest; 60 percent of the individuals interested in smoking cessation assistance desired this option (Cropsey et al., 2010).

This interest in smoking cessation is significant because in a previous study Cropsey and Kristeller (2003) found that the stages of change model was a major factor in motivating individuals to quit tobacco use altogether. The “stage of change” concept comes from a five-stage model of change introduced by two substance abuse researchers, Prochaska and DiClemente (1986). Of the five stages, Cropsey and Kristeller (2003) focused on two: precontemplation and contemplation. Individuals in the precontemplation stage have not yet begun to think about changing their behavior and may not see their substance use as a problem; individuals in the contemplation stage are willing to consider that their use is problematic and that willingness allows them to see possibility for change. Similarly, Thibodeau, Jorenby, Seal, Kim, and Sosman (2010) found that participants who either desired to remain smoke free after release or were uncertain about whether or not they would resume smoking were more likely (82 percent) to remain abstinent for at least the first month outside of a smoke-free prison environment (Thibodeau et al., 2010).

This study also found that daily cigarette smoking varied among participants, ranging from light (four cigarettes) to heavy (60 cigarettes). Half of interviewees were working toward reducing the number of cigarettes smoked daily; unfortunately, none of the participants were involved in a smoking cessation program to support this effort. Given that our sample returned to the community where cigarette smoking is prevalent, smoking cessation interventions tailored to their unique social, cultural, environmental, psychological, and general post-incarceration characteristics may be helpful to treat heavy cigarette use within the subpopulations of racial and ethnic minorities involved in the criminal justice system. In addition, involving family members, partners, and peers in smoking cessation interventions could influence newly released justice-involved men and women not to resume cigarette smoking and possibly maintain long-term abstinence.

Limitations

Although this study provides critical insight into the smoking behavior and causes for cigarette smoking in justice-involved populations, there are several potential limitations that may have affected our findings. For one, although generalizability is not of highest priority in a qualitative study, limiting our study sample to formerly incarcerated men and women from New York correctional facilities who were released to the Bronx County may have affected our ability to extrapolate our results to formerly incarcerated men and women in general. However, given that relatively little has been studied on this topic, we believe that using a purposive sample was justified as an appropriate means to advance knowledge in this area.

Furthermore, although a substantial portion of the criminal justice population does have issues with substance use, limiting our sample to individuals with histories of substance abuse may have excluded an important perspective within this population. However, it can be argued that focusing on individuals with substance use issues is, in fact, more beneficial to our study because it assists us in gathering ideas for a more comprehensive prevention plan that fits the heavy and the light smoker. Focusing on such individuals helps us develop more aggressive smoking cessation strategies tailored toward the more serious substance user; these strategies can later be tailored to fit the needs of formerly incarcerated individuals who do not have serious substance use issues but, nonetheless, need assistance quitting tobacco. Finally, because we used semistructured interviews and self-reporting for data collection, it is possible that social desirability bias could have affected the validity of our results. However, because very few participants (8.3 percent) reported having remained smoke free, it is unlikely that social desirability significantly altered our findings.

Summary

In conclusion, our study provided much needed insight into the smoking behaviors and intentions to quit of justice-involved men and women. It is clear that simply forcing these individuals to stop smoking while incarcerated is not enough. Improving access to smoking cessation products such as pharmacotherapy and family- or partner-assisted smoking cessation programs specifically for newly released justice-involved men and women could be vital in addressing cigarette smoking and improving quality of life among a highly vulnerable population.